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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:05:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 60DATE:
09/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:MELODY, LEE-ALLMOND, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Melody Lee-Allmond. The purpose of these case management inspections were to follow up on two SOC 341 self reported incident reports submitted to Community Care Licensing (CCL) that occurred on 8/20/21 and 8/27/21.

First incident, 8/20/21, facility reported R1 and R2 were aggressive towards one another and no injuries where observed. Facility staff is monitoring residents at all times and working with residents' behaviors. During visit LPA Lopez requested documents and took statements from staff and Administrator.

Second incident, 8/27/21, R3 was observed by staff with bruising. During visit LPA Lopez gathered records, made observations and took statements from staff, Administrator and R3. Facility has been in contact with ombudsman, police, APS and Community Care Licensing. Facility has also conducted internal investigation.



No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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